Does the Orthopaedic Outreach Programme “Work” for Uganda?

Richard Coughlin MD, MSc

Musculoskeletal conditions

Account for much long-term pain/disabilityHave received far less public health attention

Successful management of childhood and communicable diseases

Has shifted the burden of disease to musculoskeletal and non-communicable conditions

WHO Scientific Group 2003

Increase in life expectancy along with increase in Road Traffic Accidents

Challenges already depleted health systems

Mock et al 2004

By definition: rural, remote, disadvantaged populations have overall less healthcareAccessAvailability

Less “Health”Schlenker et al 2002

Orthopaedic Outreach Programme

With recognition of significant service delivery inequalityThe Dept of Orthopaedics at Mulago instituted the Orthopaedic Outreach Programme in 1991“provide specialized quality orthopaedic sevice to upcountry patients in their community”

Recent Cochrane Review: “Specialist Outreach Clinics in Primary Care and Rural Hospital Settings”

Gruen concludes:Need for further studies in

rural/disadvantaged “where outreach interventions may offer the most benefit to access, better health outcomes, and greater impact”

Gruen 2004

Need for Study

Very few Southern studiesMutyaba presented ASEA 2003

OOP to Fort PortalFound cost-effectivenessCost per referral patients (US $35)Cost per Outreach patient (US $8)

Methodology

Literature/Document ReviewQuantitative methodsQualitative

Key Informant Interviews(NGOs/IPH/MOH/Mulago)Semi-structured Interviews

Visited 4 Regional HospitalsMbaleAruaMasakaFort Portal (surgical camp 2004)

Limitations of Study

All interviews conducted/coded/analyzed by one ortho surgeonLack of overall burden of musculoskeletal disease in UgandaPoor follow-up on outreach resultsNo beneficiary interviews

Observations and Results

Between 1991-2002: 50 missions with MOH supportBetween 1999-2004: 67 missions with partnership with USDC

Obsevations and Results

Quantitative outputDecentralization of orthopaedic

services and decongestion of Mulago Hospital by:6,653 patients1,071 surgeries

Capacity Building Objective

New Orthopaedic surgeons at:MbararaMbaleMasaka

Qualitative Assessment

41 interviews conducted July 2004

Interviews

Mulago / Kampala

Mbale Arua Masaka Fort Portal Total

Orthopaedic Surgeons

3

2 0 1 0 6

Orthopaedic Officers

2 0 0 0 1 3

Orthopaedic Technicians

0 1 0 0 0 1

Nurses 2 0 0 0 1 3 District Dir. of Health Svcs

0 1 1 1 1 4

Medical Supervisor

0 1 1 1 1 4

Medical Officer

1 0 1 1 0 3

NGO Representative

4 1 2 1 0 8

Ministry of Health

4 0 0 0 0 4

PT / OT 0 0 2 1 2 5

Total 16 6 7 6 6 41

Barriers to Access

 

Barriers to access  

Unavailability Stigma

Poverty No money

Distance to facility Poor roads/transportation

Lack of awareness Lack of sensitization

Language barriers Cultural priorities

Deficient services Traditional healers

Fear of Mulago/Kampala Poor support services

War Security

Harms of OOPHarms of Orthopaedic Outreach Programme

To the outreach site: To the Department/Surgeon:

Opportunity costs away from PHC Time away from service/education

Increased local workload Financial loss from private practice

Depletion of supplies Demanding work schedule

Increased local costs Ethics of post-operative care

Potential worse outcomes from poor

follow-up/non-adherence

Loss of outcome information for clinical

lessons learned

Professional jealousy

Benefits of OOP to SystemBENEFITS OF OOP TO SYSTEM

Major themes Minor themes

Support/Supervision of medical officers Solidarity/Commitment to regional/district hospital

Increase in communication Improved status of health system

Support of PHC with musculoskeletal conditions

Advocacy of burden/risks/preventive measures

Medical education and skills improvement Stimulus to upgrade infrastructure

Benefits to Patients/FamilyBENEFITS OF OOP TO PATIENT/FAMILY

Major themes Minor themes

Higher standard of care Decreased stigma of disability

Lessening of economic burden Decreased reliance on traditional healers

Improved patient satisfaction Empowerment for self-improvement

Increased awareness of service Cultural and needs awareness

Decreased time to service Improved communication

Operational ConstraintsCentral Regional Local

Mulago poorly functioning as a referral hospital due to:        bureaucracy        workload        overcrowding        corruption

Declining infrastructure/ manpower/capacity        inadequate beds        inconsistent electricity        inconsistent water supply        poor x-ray machines        poor operating theatres       

Need for greater sensitization

Irregular/inadequate funding from donors MOH

Inadequate funding (capped during the last three years)

Need for greater mobilization

Need for more visits Need for data/information systems for monitoring and evaluation

Need better follow-up/ adherence

Need for improved communication, especially post-op

No funding for post-operative care/rehabilitation

Need better network/CBR

Need for improved coordination

Indifference/inadequate skills for musculoskeletal conditions

Need for ownership

Need for improved coordination

Need for improved coordination Need for improved coordination

Need for shared commitment

Need for shared commitment Need for shared commitment

What “Works” for Uganda?

Overall- “more benefit than harm”But- “single disease approach”Need for systematic, integrated surgical services delivery

That is part of a comprehensive, prioritized health care delivery system

Conclusions and Recommendations

Musculoskeletal conditions pose an increasing BOD to UgandaSurgery is increasingly seen as cost effective and possibly part of the essential package of clinical careDespite decentralization, rural/disadvantaged/”poorest of the poor” lack access

Conclusions and Recommendations cont.

Specialty Orthopaedic Outreach provides short-medium term solution to equity and access issuesOOP “works for Uganda” but

Needs improved organizationNeeds integrated surgical services and PHCNeeds follow-up, data systems, regular monitoring and evaluation

Recommendations

Obtain baseline studies to quantify need and priority interventionsStrengthen and further develop community-based rehab networkGarner greater involvement from grassroots level

Bottom-up planning/implementation/evaluation

Recommendations cont.Work toward attainment of ortho surgeons at all regional referral hospitalsCreate partnerships of all actors

MOH/Public/Private NFP Hosp/OOPPH/CBR/Civil Society(NGOs, Service Org, Prof. Societies

Greater emphasis on teaching/training/capacity buildingSustainable funding